EyeWorld is the official news magazine of the American Society of Cataract & Refractive Surgery.
Issue link: https://digital.eyeworld.org/i/146899
International insights and innovation July 2013 EW International 49 APX: Novel device for pupil expansion by Ehud I. Assia, MD "International insights and innovation" is a new regular column in EyeWorld that highlights novel techniques, instruments, and learnings from around the world. All new approaches to eyecare start with an idea. Those individuals that bring their ideas into practice are the innovators that advance the art. EyeWorld will be featuring the most creative and unique approaches to common problems from our colleagues. In our inaugural column, Ehud Assia, MD, from Israel describes a new instrument he has developed to manage small pupils. Watch for this to be available in the near future, and remember you saw it first in EyeWorld. John A. Vukich, MD, international editor Watch this video on your smartphone or iPad using your QR code reader. (Scanner available for free at your app store.) S mall pupil is a major challenge in intraocular surgery, mainly cataract surgery, that may lead to severe complications. In recent years, IFIS (intraoperative floppy iris syndrome) has become a common cause of intraoperative constricted pupil with the increasing use of alpha-1A adrenergic blockers for benign prostatic hypertrophy in men at the cataract age. There are several strategies to dilate the constricted pupil, including mechanical stretching, sphincterotomies, iris hooks, and intraocular pupillary rings, with the Malyugin ring (MicroSurgical Technology, Redmond, Wash.) being the most popular option currently. However, all of these procedures are cumbersome and time consuming and usually require excessive intraocular iris manipulations during insertion and removal. The APX (Assia Pupil Expander, APX Ophthalmology Ltd., Haifa, Israel) is a novel device for pupil dilation, based on a concept different from any other device on the market. Pupil expansion is achieved by using two devices inserted through two 19G (1.1 mm) side-port incisions opposite to each other. Each device looks like a miniature blunt scissors with a spring. A designated forceps is used to close the device during insertion and positioning. The distal curved tips are inserted behind the iris through the pupil, and releasing of the forceps results in a smooth opening of the device. Using two devices creates a quadrangular opening of about 6X6 mm. A second hook near the tip provides a firm grasp of the pupil and prevents sliding of the iris over the APX shaft. In case the tips are not positioned continued on page 50 Capsulorhexis under direct visualization in a patient with a 4-mm pupil. The APX devices are positioned horizontally. Vertical positioning of APX prior to pars plana vitrectomy. The devices did not interfere with the surgical instruments and maneuvers. Source (all): Ehud Assia, MD ALT continued from page 48 While PLT wouldn't replace the so-called glaucoma gold standard— trabeculectomy—it could replace SLT. "After trying medication, I will consider PLT," Dr. Nozaki said. "But if adherence to medications are low, I will consider PLT before I add another glaucoma medication. Before trabeculectomy, I think PLT will be a good option." Dr. Nozaki said she uses PLT regularly in her practice. "Before we got PLT, we used to use SLT," Dr. Nozaki said. "But now, mainly we use PLT." One thing to bear in mind—energy required for Asian eyes might be lower. "The power in our study was lower than in previous reports," Dr. Nozaki said. "Despite that the wave- length was different (we used a yellow wavelength), since Asian eyes have more pigment, I think the required power would be lower. Lower power might be much less thermal injury to the trabecular meshwork, so it might be beneficial for Asian eyes. We have to do a study with a larger number of patients." EW Editors' note: Dr. Nozaki has no financial interests related to this article. Contact information Nozaki: nozakim@med.nagoya-cu.ac.jp